Deficiencies (last 8 years)
Deficiencies (over 8 years)
9.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
66% occupied
Based on a November 2025 inspection.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 73
Deficiencies: 4
Date: Nov 26, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations regarding admission and care for residents exhibiting harmful behaviors, protective oversight, and policies on abuse and neglect.
Findings
The facility failed to ensure it did not admit or continue care for residents exhibiting behaviors likely to cause serious harm to themselves or others. Protective oversight was inadequate for residents displaying aggressive behaviors, and the facility lacked proper policies and procedures to prevent abuse and neglect.
Deficiencies (4)
19 CSR 30-86.047(29)(A) Not Admit/Care For-Harm Self or Others: The facility admitted or continued care for residents exhibiting behaviors with a reasonable likelihood of serious harm to themselves or others, failing to implement protective interventions. The facility census was 73.
19 CSR 30-86.047(35) Protective Oversight: The facility failed to provide 24-hour protective oversight for residents displaying aggressive behaviors, lacking timely interventions to prevent harm. The facility census was 73.
19 CSR 30-88.010(23) Develop/Implement A/N Policies: The facility failed to develop and implement written policies to prohibit mistreatment, neglect, and abuse, and failed to report incidents as required. The facility census was 73.
19 CSR 30-88.010(29) Dignity/Privacy: The facility failed to provide proper and timely care for residents, including responding to call lights, resulting in neglect of residents' dignity and privacy. The facility census was 73.
Report Facts
Facility census: 73
Inspection Report
Plan of Correction
Census: 67
Deficiencies: 1
Date: Jul 29, 2025
Visit Reason
The inspection was conducted to evaluate compliance with emergency discharge regulations following an incident involving Resident #1's discharge notification.
Findings
The facility failed to provide a safe discharge plan and did not advise the resident of the right to request an expedited appeal hearing. The discharge notification lacked required information including the resident's appeal rights and identification of a safe discharge plan.
Deficiencies (1)
19 CSR 30-88.010(18) Emergency Discharges: The facility failed to identify a safe discharge plan and did not provide the resident or next of kin with written notice of the right to request an expedited hearing during an emergency discharge.
Report Facts
Facility census: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed regarding discharge notification process | |
| Director of Wellness | Discussed safe discharge plan over phone | |
| Regional Wellness Director | Conducted audit and completed in-service training as part of plan of correction | |
| Regional VP/Regional Director of Wellness | Will review all Emergency Discharge Letters prior to submission |
Inspection Report
Plan of Correction
Census: 63
Deficiencies: 13
Date: Sep 19, 2024
Visit Reason
The inspection was conducted to assess compliance with fire safety and emergency preparedness regulations at Burlington Creek Senior Living.
Findings
The facility failed to provide documentation for annual fire drill consultation, fire safety training for employees, proper area of refuge signage and access, fire alarm system inspections and monthly tests, dryer vent maintenance, sprinkler system testing, flame-resistant curtains, approved wastebaskets, oxygen storage signage, building maintenance, electrical wiring inspections, and extension cord usage. These deficiencies potentially affected all 63 residents.
Deficiencies (13)
19 CSR 30-86.022(5)(A) Fire Drill/Evacuation Plan, Consultation: Facility failed to provide documentation of annual consultation and assistance from a local fire unit for fire drills and emergency preparedness.
19 CSR 30-86.022(6)(A)(1-3) Fire Safety Training Requirements-employees: Facility failed to produce documentation or records of fire safety training for all employees as required.
19 CSR 30-86.022(7)(D)(1-8) Area of Refuge Requirements: Facility failed to have accessible exits to grade and lacked proper signage and instructions for areas of refuge.
19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications: Facility failed to retain or provide copies of annual fire alarm system inspections and certifications.
19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test: Facility failed to show proof of monthly activation of the fire alarm system for all months in the last year.
19 CSR 30-86.022(10)(C) Clothes Dryers Vented, Lint Traps: Facility failed to keep dryer vents in good repair, resulting in malfunction codes on multiple dryer vent booster fans.
19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing: Facility failed to record monthly pressure gauge readings and valve position checks of the sprinkler system.
19 CSR 30-86.022(13)(D) Curtains/Drapes, Flame Resistant: Facility failed to show documentation that curtains and drapes were treated or certified as flame-resistant before installation.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: Facility failed to ensure all wastebaskets were metal or fire-resistant as required.
19 CSR 30-86.022(17) Oxygen Storage Requirements: Facility failed to maintain proper signage and storage for oxygen in accordance with NFPA 99 standards.
19 CSR 30-86.032(2) Substantially Constructed & Maintained: Facility failed to maintain the building and fire safety rules in good repair, including a fire door not properly latching.
19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles: Facility failed to prevent extension cords from being used with more than one electrical item and to limit use to two appliances per duplex receptacle.
State Statute A9998: Facility failed to have a current approved boiler inspection certification available as required.
Report Facts
Facility census: 63
Potentially affected residents: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Plant Operations Director | Interviewed regarding fire safety training, fire alarm system, and other deficiencies | |
| Plant Operations Assistant | Interviewed regarding fire safety training and fire alarm system monthly tests |
Inspection Report
Plan of Correction
Census: 61
Deficiencies: 1
Date: Sep 11, 2024
Visit Reason
The inspection was conducted to assess compliance with protective oversight regulations following an incident where a resident left the facility unattended and was found outside by a passerby.
Findings
The facility failed to provide adequate protective oversight for one resident who exited the facility unattended and was found outside. The resident had a history of cognitive impairment and wandering, and the facility staff were unaware the resident had left the building.
Deficiencies (1)
19 CSR 30-86.047(35) Protective Oversight: The facility failed to provide 24-hour protective oversight for one resident who left the premises unattended and was found outside. Staff were unaware the resident had left the building, posing a safety risk.
Report Facts
Facility census: 61
Inspection Report
Plan of Correction
Census: 64
Deficiencies: 3
Date: Dec 22, 2023
Visit Reason
The inspection was conducted to assess compliance with tuberculosis screening, personnel record requirements, and influenza/pneumococcal vaccination documentation at Burlington Creek Senior Living.
Findings
The facility failed to ensure required two-step tuberculosis screening for staff and volunteers, lacked written and signed physician statements for staff personnel files, and did not document residents' opportunity to refuse influenza vaccination. The facility census was 64 at the time of inspection.
Deficiencies (3)
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to ensure the required two-step tuberculosis screening test was completed for five of five sampled staff members. The facility census was 64.
19 CSR 30-86.047(20)(I) Personnel Record: The facility failed to maintain a written and signed statement by a licensed physician or designee indicating staff could work in a long-term care facility for five of five sampled staff members. The facility census was 64.
19 CSR 30-86.047(47)(F)(2) Influenza/Pneumococcal Documented Assessment: The facility failed to document the opportunity to refuse influenza vaccination for two of six sampled residents. The facility census was 64.
Report Facts
Facility census: 64
Sampled staff members: 5
Sampled residents: 6
Inspection Report
Plan of Correction
Census: 71
Deficiencies: 5
Date: Jul 5, 2023
Visit Reason
The inspection was conducted to assess compliance with fire safety and emergency preparedness regulations, including fire drills, fire alarm system tests, smoke section partitions, sprinkler system maintenance, and boiler inspection certification.
Findings
The facility failed to provide documentation for required fire drills and fire alarm system activations. Observations and interviews revealed issues with smoke partition doors, sprinkler system pressure gauge readings, and expired boiler inspection certification. The facility census was seventy-one residents.
Deficiencies (5)
19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation. The facility failed to produce documentation of at least 12 fire drills conducted annually and at least one fire drill per shift every three months. The facility census was 71 residents.
19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test. The facility failed to show proof of monthly fire alarm system activation. The facility census was 71 residents.
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds. The facility failed to ensure smoke stop partition doors properly closed during a fire alarm. The facility census was 71 residents.
19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13. The facility failed to perform monthly pressure gauge readings and valve position checks of the sprinkler system. The facility census was 71 residents.
19 CSR 30-86.032(2) Substantially Constructed & Maintained. The facility failed to have a current approved boiler inspection certification; the previous certification expired on 5/13/23. The facility census was 71 residents.
Report Facts
Facility census: 71
Fire drills required annually: 12
Fire drills required per shift every three months: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paul Sasser | Executive Director | Signed plan of correction approval |
| Director of Maintenance | Interviewed regarding fire drills, fire alarm system, smoke doors, sprinkler system, and boiler inspection |
Inspection Report
Plan of Correction
Census: 89
Deficiencies: 5
Date: Nov 16, 2022
Visit Reason
The inspection was conducted to assess compliance with health and sanitation regulations related to kitchen cleanliness, chemical sanitization, and equipment maintenance at the facility.
Findings
The facility failed to maintain cleanliness of walls, ceilings, doors, windows, vents, and kitchen equipment. Chemical sanitization procedures were not properly followed, including lack of PPM measurement and improper dishwasher temperature monitoring.
Deficiencies (5)
19 CSR 30-87.020(15) Walls/Ceilings/Doors/Windows Clean: Facility failed to keep walls, floors, and baseboards in the kitchen clean and free from dirt and debris as observed on multiple surfaces.
19 CSR 30-87.020(19) List Fixtures, Vent Covers, Décor Cleanable: Facility failed to keep vent covers in the kitchen clean and free from dirt and debris.
19 CSR 30-87.030(74) Chemical Sanitization, PPM Measured: Facility failed to ensure chemical sanitizer used had correct parts per million (PPM) and lacked procedures and records for measuring PPM.
19 CSR 30-87.030(82) Machines with Hot Water Sanitizing: Facility failed to ensure high temperature dishwasher temperature was checked daily and dishwasher temperature was below required levels.
19 CSR 30-87.030(86) Store Equip/Utensils to Prevent Contamination: Facility failed to ensure cleaned and sanitized utensils and equipment were stored above the floor in a clean, dry location to prevent contamination.
Report Facts
Facility census: 89
Deficiency count: 5
Inspection Report
Life Safety
Census: 83
Deficiencies: 3
Date: Jun 7, 2022
Visit Reason
The inspection was conducted to assess compliance with fire safety and life safety code regulations, including fire drill/evacuation plan requirements, sprinkler system maintenance, and building construction and maintenance standards.
Findings
The facility failed to meet fire drill and evacuation plan requirements, did not maintain complete sprinkler system monthly checks and documentation, and failed to maintain the building in good repair, including a stuck exit door that could trap residents during a fire.
Deficiencies (3)
19 CSR 30-86.022(5)(B)(1 - 10) Fire Drill/Evacuation Plan Requirements were not met as the facility failed to ensure all floor plans showed two evacuation routes, locations of fire alarm pull stations, and fire extinguishers.
19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13 was not met as the facility failed to perform monthly pressure gauge readings and valve position checks, and no records were kept.
19 CSR 30-86.032(2) Substantially Constructed & Maintained was not met as the facility failed to maintain the building in good repair, including a stuck exit door in the area of refuge that would not open, potentially trapping residents.
Report Facts
Facility census: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Plant Operations | Interviewed regarding evacuation plans, sprinkler system checks, and exit door repairs | |
| Executive Director | Responsible for completing random audits to ensure compliance |
Inspection Report
Plan of Correction
Census: 85
Deficiencies: 1
Date: Jul 19, 2021
Visit Reason
The inspection was conducted to evaluate compliance with oxygen storage requirements as per NFPA 99, 1999 Edition, following observations of oxygen storage practices in various rooms.
Findings
The facility failed to ensure oxygen storage was in accordance with NFPA 99 standards. Multiple unsecured oxygen bottles were observed in resident rooms and the oxygen storage room, with missing precautionary signage on doors.
Deficiencies (1)
19 CSR 30-86.022(17) Oxygen Storage Requirements: The facility failed to secure oxygen bottles and display precautionary signage as required by NFPA 99, 1999 Edition. Observations showed unsecured oxygen bottles in rooms 103, 114, and 115, and the oxygen storage room.
Report Facts
Facility census: 85
Oxygen amount: 7260
Inspection Report
Plan of Correction
Census: 81
Deficiencies: 1
Date: May 11, 2021
Visit Reason
The inspection was conducted to evaluate compliance with discharge appeal rights regulations, specifically regarding the facility's failure to provide full and adequate notice of discharge and the right to a hearing.
Findings
The facility failed to discharge a resident with full and adequate notice of their right to a hearing before the department's Administrative Hearings Unit. The facility census was 81 at the time of inspection.
Deficiencies (1)
19 CSR 30-88.010(17) Discharge Appeal Rights: The facility failed to provide a resident with full and adequate notice of their right to a hearing before the department's Administrative Hearings Unit and an opportunity to be heard on the necessity of discharge.
Report Facts
Facility census: 81
Inspection Report
Plan of Correction
Census: 79
Deficiencies: 2
Date: Apr 1, 2021
Visit Reason
The inspection was conducted to assess compliance with personnel record requirements and insulin administration certification for staff at Anthology of Burlington Creek.
Findings
The facility failed to maintain complete personnel records documenting licensure, training, and certification for employees, specifically lacking insulin administration certification for several medication aides. The facility also failed to ensure that only certified staff administered insulin to residents.
Deficiencies (2)
19 CSR 30-86.047(20)(E) Personnel Record - exp/training/license/ed. The facility failed to maintain documentation of experience, education, and competency for five sampled employees. The facility census was 79.
19 CSR 30-86.047(45) Injections, Insulin Administration. The facility failed to assure staff had completed certification for insulin therapy for three of four sampled employees. The facility census was 79.
Report Facts
Facility census: 79
Number of sampled employees lacking certification: 3
Number of sampled employees lacking documentation: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| L1MA A | Level One Medication Aide | Named in personnel record and insulin certification deficiencies |
| L1MA B | Level One Medication Aide | Named in personnel record and insulin certification deficiencies |
| L1MA C | Level One Medication Aide | Named in personnel record and insulin certification deficiencies |
| L1MA D | Level One Medication Aide | Named in personnel record and insulin certification deficiencies |
| L1MA E | Level One Medication Aide | Named in personnel record and insulin certification deficiencies |
Inspection Report
Plan of Correction
Census: 63
Deficiencies: 8
Date: Mar 11, 2020
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Anthology of Burlington Creek, detailing regulatory violations found during a survey completed on 03/11/2020 and the facility's corrective actions.
Findings
The facility failed to comply with multiple regulatory requirements including Employee Disqualification List checks, criminal background checks, identification badge usage, tuberculosis screening, medication reconciliation, medication destruction, hand hygiene, and documentation of resident rights. Deficiencies were identified through record reviews, observations, and interviews.
Deficiencies (8)
19 CSR 30-86.047(12) EDL Requirements: The facility failed to ensure staff checked the Employee Disqualification List before employees had contact with residents. Three of five sampled employees lacked EDL verification.
19 CSR 30-86.047(13)(A) Criminal Background Check Requirements: The facility failed to conduct criminal background checks or Family Care Safety Registry checks for three of five sampled employees prior to resident contact.
19 CSR 30-86.047(16) Identification Badge Requirements: The facility failed to ensure all staff wore identification badges while on duty, as observed with multiple staff members not wearing badges.
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to maintain tuberculosis screening documentation for five of five sampled employees, lacking evidence of required TB tests.
19 CSR 30-86.047(51)(A)(1) Schedule II Meds-Reconcile Each Shift, Record: The facility failed to reconcile controlled substance medications each shift, with missing signatures on narcotic logs for multiple days.
19 CSR 30-86.047(56)(E)(1-2) Medications-Return to RX / Destroy, Records: The facility failed to ensure staff destroyed expired medications for four of ten sampled residents, with expired medications observed in storage.
19 CSR 30-87.030(2) Wash Hands/Arms & Clean Fingernails: The facility failed to ensure food preparation staff washed hands as required, with Cook A observed not washing hands during food preparation.
19 CSR 30-88.010(6) Disclosure of Res Rights Info Documented: The facility failed to document the annual review of resident rights for five of six sampled residents, with missing resident rights forms and signatures.
Report Facts
Facility census: 63
Number of sampled employees: 5
Number of sampled residents: 10
Number of sampled residents: 6
Number of sampled employees: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook A | Observed not washing hands and not wearing ID badge during food preparation | |
| Care Manager A | Observed not wearing ID badge while on duty | |
| Server A | Observed not wearing ID badge while on duty | |
| Server B | Observed not wearing ID badge while on duty | |
| Kitchen Assistant | Observed not wearing ID badge while on duty |
Inspection Report
Plan of Correction
Census: 84
Deficiencies: 2
Date: Dec 24, 2019
Visit Reason
The inspection was conducted to assess compliance with care standards, specifically focusing on individualized service plans and medication administration documentation.
Findings
The facility failed to provide proper care per individualized service plans, including lack of assistance during meals and incomplete medication administration documentation for sampled residents.
Deficiencies (2)
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan. The facility failed to provide proper care per the individualized service plan for one sampled resident who was not assisted during meal time.
19 CSR 30-86.047(47)(G) Medication Administration, Documented. The facility failed to ensure medication administration was recorded on the Medication Administration Record for one sampled resident.
Report Facts
Facility census: 84
Inspection Report
Plan of Correction
Census: 72
Deficiencies: 9
Date: May 21, 2019
Visit Reason
The inspection was a change of operator fire safety portion inspection conducted on 5/21/2019 at Anthology of Burlington Creek.
Findings
The facility failed to meet multiple fire safety regulations including incomplete fire alarm systems, failure to maintain self-closing hazardous area doors, improper storage of combustible materials, non-flame resistant curtains, use of improper wastebaskets, inadequate trash removal, unsecured oxygen bottles, improper electrical wiring maintenance, and unsafe use of extension cords. Corrective actions and plans of correction were provided for each deficiency.
Deficiencies (9)
19 CSR 30-86.022(9)(A)(1) Smoke Detectors-NFPA 13: The facility failed to have smoke detectors installed in spaces open to corridors as required by NFPA 101. The fitness room door was mechanically blocked open.
19 CSR 30-86.022(10)(A) Hazardous Area Requirements: The facility failed to maintain and keep closed a self-closing smoke partition door to a hazardous area. The laundry room door was mechanically blocked open.
19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage Of: The facility failed to keep unnecessary combustible materials out of the building, with a dirty mattress and box springs stored in the mechanical/electrical room.
19 CSR 30-86.022(13)(D) Curtains/Drapes, Flame Resistant: The facility failed to provide documentation that curtains in the fitness room were flame resistant as required by NFPA 101.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: The facility failed to ensure all wastebaskets were the approved types; many improper wastebaskets were found throughout the facility.
19 CSR 30-86.022(15)(B) Trash Removal for Safety: The facility failed to remove trash as needed to prevent fire hazards; large trash containers with trash were stored in laundry rooms.
19 CSR 30-86.022(17) Oxygen Storage Requirements: The facility failed to properly secure oxygen bottles; unsecured oxygen bottles were found in multiple rooms and storage areas.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: The facility failed to properly maintain electrical wiring; power strips hanging by tangled wires and loose GFCIs were observed.
19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles: The facility failed to limit use of extension cords and duplex receptacles; multiple 3-way adapters and extension cords were improperly used in resident rooms.
Report Facts
Facility census: 72
Wastebaskets counted: 12
Oxygen bottles unsecured: 3
Oxygen bottles unsecured: 16
Oxygen bottles unsecured: 2
Oxygen bottles unsecured: 4
Trash container size: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding door closures, wastebasket stock, trash removal, and electrical safety corrections | |
| D.O.N. | Interviewed about oxygen bottle storage corrections |
Inspection Report
Plan of Correction
Census: 76
Deficiencies: 1
Date: Dec 27, 2018
Visit Reason
The document is a plan of correction submitted following a deficiency related to proper care per the Individual Service Plan (ISP) for a resident with catheter care needs.
Findings
The facility failed to ensure staff followed one resident's ISP for catheter care, including proper cleaning and use of wipes. Observations and interviews confirmed staff did not follow correct catheter care procedures.
Deficiencies (1)
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan. The facility failed to ensure staff followed one resident's ISP for catheter care, including proper cleaning and use of wipes. Staff cleaned the catheter improperly by reusing wipes and not following sterile procedures.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding catheter care procedures and staff compliance. |
| Certified Nurse Assistant A | Certified Nurse Assistant | Interviewed about catheter care procedures and use of wipes. |
Inspection Report
Life Safety
Census: 69
Deficiencies: 7
Date: Sep 19, 2018
Visit Reason
The inspection was a licensure inspection focused on fire safety and life safety code compliance at Stonecrest at Burlington Creek.
Findings
The facility failed to meet multiple fire safety regulations including exit sign illumination, smoke detector installation, atrium smoke separation, smoke section partitions, wastebasket requirements, oxygen storage, and electrical wiring inspection documentation. These deficiencies affected all 69 residents present during the inspection.
Deficiencies (7)
19 CSR 30-86.022(8)(C) Exit Sign-Illumination: The facility failed to provide illumination to all exit signs at all exits, including those on the memory care unit, due to non-functioning emergency batteries.
19 CSR 30-86.022(9)(A)(1) Smoke Detectors-NFPA 13: The facility failed to have smoke detectors installed in open corridor spaces, with some doors mechanically blocked open and smoke detectors not tied into the fire alarm system.
19 CSR 30-86.022(10)(F) Atriums: The facility failed to ensure resident room corridors were separated from the atrium by one-hour rated smoke walls, with atrium fire doors not latching and closing fully.
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds: The facility failed to ensure smoke stop partition doors properly closed during a fire alarm, with doors rubbing on frames and loose catches.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: The facility failed to ensure all wastebaskets were metal or UL/FM fire-resistant rated, with multiple rooms having improper wastebaskets.
19 CSR 30-86.022(17) Oxygen Storage Requirements: The facility failed to monitor oxygen bottle storage in resident rooms according to NFPA 99, with multiple oxygen bottles free standing in various rooms.
Electrical wiring inspection: The facility failed to show documentation of electrical wiring inspection within the last two years by a qualified electrician, as required for facilities built prior to July 1, 2005.
Report Facts
Facility census: 69
Deficiencies cited: 7
Inspection Report
Follow-Up
Census: 75
Deficiencies: 1
Date: Jun 21, 2018
Visit Reason
The inspection was conducted to assess compliance with call system requirements in the memory care unit of the assisted living facility.
Findings
The facility failed to maintain call lights in good working condition in the memory care unit. Several call light cords were difficult to pull or did not send notifications to staff tablets as required.
Deficiencies (1)
19 CSR 30-86.032(33) Call Systems Requirements: The facility failed to maintain call lights in good condition in the memory care unit, with cords difficult to pull and notifications not sent to staff tablets.
Report Facts
Facility census: 75
Emergency call lights checked weekly: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) | Interviewed regarding call light notifications and observations | |
| Maintenance Staff A | Interviewed about checking emergency call lights weekly | |
| Executive Director | Interviewed about call light functionality and compliance |
Inspection Report
Plan of Correction
Census: 78
Deficiencies: 9
Date: May 24, 2018
Visit Reason
The inspection was conducted to assess compliance with state regulations for an assisted living facility, including tuberculosis screening, individualized service plans, medication management, backflow prevention, and food safety.
Findings
The facility was found deficient in multiple areas including failure to screen residents for tuberculosis, incomplete individualized service plans, lack of signatures on service plans, medication self-administration without proper physician orders, failure to maintain monthly summaries and weights, lack of backflow preventers on shower hoses, inadequate handwashing by food preparation staff, and improper cooking temperatures for potentially hazardous foods.
Deficiencies (9)
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to screen residents #5 and #6 for tuberculosis as required by state regulations.
19 CSR 30-86.047(28)(H) Individual Service Plan - Review Requirements: The facility failed to ensure four of eight sampled residents had individualized service plans completed upon admission and annually.
19 CSR 30-86.047(28)(I) Individual Service Plan - Signatures: The facility failed to ensure two of eight sampled residents had service plans signed by authorized representatives and residents upon admission and annually.
19 CSR 30-86.047(40) Self-Control of Medication Requirements: The facility failed to ensure seven residents had physician orders for self-administration of medications and that medications were current with physician orders.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review: The facility failed to complete monthly summaries including weights for eight sampled residents.
19 CSR 30-87.020(28) Backflow Requirements: The facility failed to ensure backflow preventers were installed on all shower hoses extending below the flood plane.
19 CSR 30-87.030(2) Wash Hands/Arms & Clean Fingernails: The facility failed to ensure food preparation staff washed hands and changed gloves as necessary during dishwashing.
19 CSR 30-87.030(26) Hazardous Food Cooking Temperatures: The facility failed to ensure potentially hazardous foods were cooked to required internal temperatures, including non-pasteurized eggs served to residents.
19 CSR 30-88.010(10) Advance Directive Requirements: The facility failed to ensure accurate advance directive information was present in resident records for two sampled residents.
Report Facts
Facility census: 78
Deficiencies cited: 9
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